Remotely delivered chronic disease management programs can lower barriers and increase access to care for populations who've been traditionally underserved by health care. A large health care system evaluated a remote blood pressure and low-density lipoprotein cholesterol (LDL-C) program to determine whether the model was scalable at a population level and could meet the needs of a diverse population.

In the program, nonlicensed navigators supervised by pharmacists, NPs, and physicians coordinated patient care using customer relationship management software, streamlined task automation, clinical decision support algorithms, and omnichannel communication.

A total of 10,803 patients 26 to 80 years of age who had blood pressure and/or LDL-C levels above guideline-recommended targets were enrolled in the program, which included education, home blood pressure device integration, and medication titration. An education-only cohort of 1,266 patients agreed to receive dietary, lifestyle, and medication advice but declined to participate in home blood pressure monitoring and program medication titration.

At six months and again at one year, mean office systolic and diastolic blood pressure was significantly lower in the medication management cohort than in the education-only cohort. Mean LDL-C reduction was significantly greater in the medication management cohort than in the education-only cohort. Rates of enrollment and clinical benefits were similar regardless of race, ethnicity, and preferred language.

Because the intervention was not randomized, it wasn't possible to prove a causal relationship between the intervention and the outcomes. Also, many patients didn't complete the program.